Medical Billing

Medicare

federal health insurance program mainly for people age 65 and older, or for certain younger individuals with disabilities

Parts of Medicare

PART A - Hospital Insurance
PART B - Medical Insurance

PART C - Medicare Advantage Plans

PART D - Prescription Drug Coverage

Part A and Part B are what are shown on the Medicare Card.

Medicare as a Second Payer (MSP)

Common situations:

• Working aged, covered by group health plan through current employment or spouse’s current employment

  • individual aged 65+, self-employed & covered by group health plan through their current employer/spouse’s current employment, and employer has 20 or more employees

• Is disabled and covered by a group health plan

  • disabled + covered by group health plan via current employment / family member’s current employment, and employer has 100

• has end-stage renal disease (ESRD) and a group health plan

  • + is in first 30 months of eligibility or entitlement to Medicare. Applicable for the 30-month coordination period for ESRD

  • OR + is covered by a Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA plan) and is in the first 30 months of eligibility or entitlement to Medicare. Applicable for the 30-month coordination period for ESRD

• was in an accident or occurrence in which no-fault or liability insurance is involved

  • if entitled to Medicare and was in accident or other situation where no-fault or liability insurance is involved

• is covered under workers’ comp insurance

  • if entitled to Medicare and is covered under workers’ comp because of a job-related illness or injury, workers’ comp is the primary for healthcare items or services related to job-related illness or injury claims

NPI + Credentialing

CAQH (Council for affordable quality healthcare) - streamlines and gathers this information

Status Code

Tells you how Medicare covers and pays for a specific procedure or service under the Physician Fee Schedule (PFS)

Medigap

Medicare supplemental policy that is sold by private insurance companies to help cover some of the costs that orignal Medicare does not cover (i.e. deductibles, copayments, coinsurances)

Some policies may offer coverage for services not covered by Medicare (i.e., coverage if a patient is i

MUE (Medically Unlikely Edits)

Define maximum units of service that a provider would report, under most circumstances, for a single Beneficiary, on a single date of service, for a specific HCPCS/CPT code

• Practitioner services MUE values: indicates number of units that may be billed for the HCPCS Level II code or CPT code

• MUE adjudication Indicator (MIA): indicates type of MUE and its basis

  • 2: an edit for which MUE is based on regulation or sub-regulatory instructions (policy), including the instruction that is inherent in the code descriptor or its applicable anatomy

  • 3: an edit for which the MUE is based on clinical information, such as billing patterns, prescribing instructions, or other info

  • 3 is the most common per day edit

• MUE rationale: specifies adjudication indicator as to whether it is due to anatomic consideration, nature of service, code descriptor or CPT instruction, clinical data, or CMS policy

Part of NCCI edits that places limits on the frequency that individual codes can be billed on a single date of service by a single provider for a single beneficiary

TRICARE

DOD (department of Defense0 healthcare program for military families and retirees

Types of Plans

• TRICARE Prime

• TRICARE Select

• TRICARE for Life

• TRICARE Reserve Select

• TRICARE Retired Reserve

• TRICARE Young Adult

  • US Family Health Plan

CHAMPVA

Civilian Health and Medical Program of the Department of Veterans Affairs

• healthcare program in which department of veterans affairs covers spouses, widows & widowers, and children of veteran who is rated permanently and totally disabled due to a service-connected disability, died of a service-connected disability, or died on active service and the dependents are not eligible for TRICARE

What do you do if there is a CPT and HCPCS code that code for the same thing for Medicare?

Use HCPCS code!

What do you do if there is a CPT and HCPCS code that code for the same thing for other insurances?

review their terms, but most will probably go for the CPT code!H

HCPCS Level II Codes

Explains what else was used (supplies, equipment, and drugs)

CPT Code

Explains what the provider did (procedures + service)

ICD-10-CM

Explains why the patient was seen (diagnosis)

Reject Claim

claim not containing the necessary information for adjudication

Denied Claim

one that passed through payer’s initial claim processing but was determined not to be a covered service or procedure based on the payer’s coverage criteria.

Anti-Kickback

Knowing and willfully offering or accepting rewards or renumeration for services that are billable to a federal healthcare plan

Conditions of Participation

Conditions that healthcare organizations must meet to participate with the plan or program

Covered Entity

Defined as health plans, healthcare clearinghouse, and healthcare providers who electronically transmit any health info in connection with transactions for which HHS has adopted standards

-HIPAA

False Claims Act

Federal statute setting criminal and civil penalties for falsely billing the government, over-representing the amount of a delivered product, or under-stating an obligation to the government

Fraud

Making false statements to misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program

Abuse

conduct inconsistent with accepted standards that causes unnecessary costs, often without malicious intent

Protected Health Information (PHI)

Individually identifiable health info that includes many common identifiers (demographic data, name, address, birth date, social security number, etc.). Also includes info that relates to an individual’s past, present, or future physical or mental health or condition;

provision of health care to individual;

or, past/present/future payment for provision of healthcare to the individual, which reasonably may be used to identify an individual

Qui Tam action

lawsuit brought by a private citizen against a person or company who is believed to have violated the law in performance of a contract with the government or in violation of a government regulation, when there is a statute which provides for a penalty for such violations

Stark Law

Federal Law that places limitations of certain physician referrals

Truth in Lending Act

Designed to assure that every customer who needs consumer credit is given meaningful info concerning the cost of such credit

Accountable Care Organizations (ACO)

a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients

Patient Protection and Affordable Care Act (ACA)

Health insurers offering group or individual coverage must implement an effective appeal process for appeals of coverage determinations and claims

Coordination of Benefits (COB)

Process of determining which of two or more insurance policies will have the primary responsibility of processing a claim and the extent to which the other policies will contribute

Exclusive Provider Organization (EPO)

organization that has entered into contracts with medical care providers or groups of medical care providers to provide healthcare services to members

Flexible Spending Account (FSA)

Tax-advantaged healthcare account an individual contributes money into that is used to pay for certain out-of-pocket healthcare costs

Health Maintenance Organization HMO

organization that provides comprehensive healthcare to voluntarily enrolled individuals and families in a geographic area by member physicians with limited referral to outside specialists, and that is financed by fixed periodic payments determined in advance

Health Savings Account (HSA)

Savings account used in conjunction with a high-deductible health insurance policy that allows users to save money tax-free against medical expenses

Healthcare Reimbursement Arrangement (HRA)

An employer-funded plan that reimburses employees for incurred medical expenses that are not covered by the company’s standard insurance plan

Individual Health Plans

Health plans that are purchased by individuals for themselves or their families, not as part of a group plan

Managed Care Organization (MCO)

Organization that combines functions of health insurance, deliver of care, and administration

Management Service Organization (MSO)

Business providing nonclinical services to providers, like practice management service, to individual physician practices

Physician-hospital organization (PHO)

Organization that is owned by hospitals and physician groups working cooperatively to develop improved methods of healthcare delivery, oversee integration of physicians and hospitals into health delivery networks, assist in voluntary group formation, and collect, analyze, and disseminate informationPr

Primary Care Provider (PCP)

healthcare practitioner, such as a family practitioner, internist, or pediatrician who is chosen by an individual to provide continuous medical care, trained to treat a wide variety of health-related problems

Responsible for supervising and coordinating healthcare services for patients

Health Insurance Portability and Accountability Act (HIPAA)

includes privacy rule, which regulates use and disclosure of protected health info (PHI)

National Correct Coding Initiative (NCCI)

used by professional billers to determine codes considered by CMS to be bundled codes for procedures and services deemed necessary to accomplish a major procedure. This is to promote correct coding methodologies and to control improper assignment of codes that result in inappropriate reimbursement

Advanced Beneficiary Notice (ABN)

standardized form that explains to the patient why Medicare may deny the particular service or procedure. An ABN protects the provider’s financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure

Medical Administrative Contractor (MAC)

A company under contract with the federal government to handle claims processing for Medicare services within a specific geographic jurisidiction

Adjudication

Determination of insurer’s payment amount after the member’s insurance benefits have been applied

Birthday Rule

health plan of parent whose birthday comes first in the calendar year is designated as the primary plan

Fair Debt Collection Practices Act (FDCPA)

third-party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred for personal, family, or household purposes

Fair Credit Reporting Act

protects info collected by consumer reporting agencies such as credit bureaus, medical info companies, and tenant screening services

Fee-for-Service (FFS)

payment model where payment is made to a provider for each individual service rendered to a patient.

Prompt Payment Act

Federal Law that ensures federal agencies pay their bills within 30 days of receipt and acceptance of materials and/or servicesE

Early and periodic Screening, Diagnostic and Treatment (EPSDT)

Medicaid benefit that provides comprehensive and preventive healthcare services for enrolled children under the age of 21

Non-Participating Provider

physician, hospital, or other healthcare entity that does not have a participating agreement with an insurance plan’s network

Participating Provider

physician, hospital, or other healthcare entity that is a part of an insurance plan’s network

Relative Value Unit (RUV)

Measure of value used by Medicare in the Resource-based relative value system

Resource Based Relative Value System (RBRVS)

system of payments to physicians for treating Medicare patients that considers the work done by physicians, malpractice insurance, and practice expenses including staff salaries, overhead supplies, and equipment

Indemnity

Also known as traditional insurance or fee-for-service

is a traditional insurance plan that reimburses for healthcare services provided to members based on provider’s bill submitted after the services are rendered

Point of Service (POS)

Coverage is a healthcare option that allows members to choose medical services as needed, and whether they will go to a provider within the Blue Cross Blue Shield network or seek medical care outside of the network

Preferred Provider Organization (PPO)

plan allowing members to choose any provider but offers higher levels of coverage if members receive services from healthcare providers in the plan’s PPO network

Commercial Workers’ Compensation Insurance

commercial insurance companies that comply with state mandates for workers’ comp coverage can offer policies that employers may purchase

Energy Employees Occupational Illness Compensation Program

provides lump sum compensation and health benefits for eligible Department of Energy nuclear weapons workers injured on the job

Federal Employees’ Compensation Program

Provides workers’ comp coverage to three million federal and postal workers around the world for employment-related injuries and occupational diseases

Federal Black Lung Program

An act which provides compensation and medical coverage for treatment to coal miners who are totally disabled by pneumoconiosis arising out of coal mine employment, and to survivors of coal miners whose deaths are attributable to the disease

Longshore and Habor Workers’ Comp Program

Provides workers’ comp benefits to most waterfront workers and contractors working overseas for the U.S. government

Self-Insurance Plans

Employers with adequate capital to qualify can self-insure. Employers are required to set aside state-mandated percentage of capital funds to cover medical expenses, wage, compensation, and other benefits payable to employees who have an on-the-job injury and/or illness

State Insurance Fund

Is an agency that provides workers’ compensation insurance coverage to private and public employers and acts as an agent in state workers’ compensation cases involving state employees.